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Parenteral nutrition in ICU patients

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Title: Parenteral nutrition in ICU patients


1
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2
Parenteral nutrition in ICU patients
Dr Mohammad Safarian
3
Who need nutritional support?
  • Malnourished one or more of the following
  • BMI lt 18.5 kg/m²
  • weight loss gt 10 within the last 3-6 months
  • BMI of lt 20 kg/m² and weight loss gt 5 within the
    last 3-6 months

4
Who need nutritional support?
  • At risk of malnutrition one or more of the
    following
  • NPO for gt 5 days and/or likely to be NPO for
    the next 5 days or longer.
  • poor absorptive capacity, are catabolic and/or
    have high nutrient losses and/or have increased
    nutritional needs

5
Consider oral nutrition support
if patient malnourished/at risk of malnutrition
and
can swallow safely and gastrointestinal tract is
working
stop when the patient is established on
adequate oral intake from normal food
6
Consider enteral tube feeding
if patient malnourished/at risk of
malnutrition despite the use of oral interventions
and
has a functional and accessible gastrointestinal
tract
use the most appropriate route of access and mode
of delivery
stop when the patient is established on
adequate oral intake from normal food
7
Consider parenteral nutrition
if patient malnourished/at risk of malnutrition
and has either
a non-functional, inaccessible or
perforated gastrointestinal tract
inadequate or unsafe oral or enteral nutritional
intake
introduce progressively and monitor closely
use the most appropriate route of access and mode
of delivery
stop when the patient is established on
adequate oral intake from normal food or enteral
tube feeding
8
Do not consider EN
  • GI obstruction with no access to GI after
    obstruction.
  • Ileus
  • High-output enteric fistula (gt500ml/d)
  • Sever vomiting or diarrhea
  • Acute pancreatitis.
  • Refusal of patient or legal guardian.

9
Parenteral Nutrition Indications
  • Severe malnutrition and prolonged NPO status (gt5
    days).
  • Significant catabolism and prolonged NPO status
  • Bowel obstruction/ileus
  • Chronic vomiting/diarrhea
  • Use of GI tract contraindicated
  • Malabsorption
  • Bowel rest (severe pancreatitis)
  • Initially in short bowel syndrome

10
Parenteral Nutrition Contraindications
  • Functioning GI tract
  • No safe venous access
  • Hemodynamically unstable
  • Patient not desiring aggressive support

11
Total Parenteral Nutrition
  • Goal In TPN Formulation
  • Provide all a patients required nutrients in a
    fluid volume that is well tolerated.

12
Total Parenteral Nutrition
Normal Diet TPN
Protein.. Amino Acids
Carbohydrates.. Dextrose
Fat Lipid Emulsion
Vitamins... Multivitamin Infusion
Minerals... Electrolytes and Trace Elements
13
Solutions CHO Dextrose
  • Supplied as dextrose 10 to 35
  • 10 100 gm/L, 25 250 gm/L
  • Dextrose provides 3.4 Kcal/gm
  • 1 liter of 10 soln (100gm x 3.4Kcal/gm)
  • 340 Kcal
  • PPN Peripheral Parenteral Nutrition is put into
    peripheral vein. So, more than D10 cannot be used.

14
Solutions Protein
  • Supplied as Amino acids essential
    nonessential
  • Choices
  • 5, 10 solutions
  • 5 50 gm/L
  • Protein provides 4 Kcal/gm.

15
Parenteral Nutrition Solutions Lipids
  • Supplied as aqueous suspension of soybean or
    safflower oil with egg yolk phospholipids as the
    emulsifier.
  • Glycerol is added to suspension.
  • 2 levels of emulsions
  • 10 solution 1.1 kcal/mL
  • 20 solution 2.0 kcal/mL
  • Lipid emulsion , when given alone, should be
    completely infused within 12 hours of hanging of
    emulsion.

16
Parenteral Nutrition Solutions
  • Guidelines for amounts of each to provide
  • CHO 50-65 of kcal
  • Lipids 30 of kcal
  • Protein 15 - 20 of kcal
  • Fluid 1.5 - 2.5 liters
  • Kcal N ration 125 kcal1 gm N

17
Parenteral Nutrition Solutions
  • Prepared aseptically delivered in 2 ways
  • 3 in 1 solution protein, fat and CHO in one
    bag and 1 pump is used to infuse solution.
  • 3 in 2 solutions 2 bag method protein CHO
    in 1 bag lipid solution in glass bottle each
    is hooked up to pump solutions enter vein
    together.
  • Given continuously or cyclically (8-12 hrs/day).
  • Insulin may be added to solution.

18
Rate of infusion
  • Glucose
  • Start slowly to a target rate of 5mg/kg/min
    check blood sugar every 6 hrs. adjust the rate to
    keep blood sugar below 150mg/dl, or add insulin
    infusion.
  • Amino acids
  • Start at a lower dose and rate and increase
    gradually to desired goal.
  • Lipids
  • Start slowly to a target rate of 0.05g/kg/hr.Do
    not exceed the max. rate of 0.11g/kg/hr. adjust
    the dose and rate by checking plasma triglyceride
    levels.

19
Care of catheter
  • The catheter should be inserted under all aseptic
    precautions.
  • Always obtain a chest X-ray to confirm the
    position of the catheter before starting PN.
  • The catheter should be inspected daily and clean
    with alcohol based solution.
  • Avoid drawing blood from TPN line.
  • Avoid infusing medications through TPN line.

20
Monitoring
21
  • Which type of complications?
  • Who may be at risk?
  • Early detection and treatment?

22
Monitoring of PN therapy
  • The main objectives
  • To ensure about safety, and early detection and
    treatment of complications
  • To assess the extent to which nutritional
    objectives have been reached.
  • To alter the type or components of the regimen,
    to improve its effectiveness and to prevent
    complications.

23
General considerations
  • Basic clinical observations (temperature, pulse,
    oedema)
  • Observations of feeding technique and its
    possible complications
  • Measures of nutritional intake.
  • Weight changes
  • Fluid balance charts (in hospital)
  • Laboratory data
  • Outcome factors (complications, improvements)
  • Change in socio-psychological state which might
    influence nutritional therapy

24
Monitoring in PN therapy
  • Weight(on a daily basis,initialy and )
  • BloodDaily Electrolytes (Na, K, Cl-)
    Glucose Acid-base status3 times/week
    BUN Ca, P Plasma transaminases

25
Monitoring in PN therapy
Variable to be monitored Initial Later period
Clinical status Daily Daily
Catetheter site Daily Daily
Temperature Daily Daily
Intake Output Daily Daily
26
Monitoring in PN therapy
Variable to be monitored Initial Later period
Weight Daily Weekly
serum glucose Daily 3/wk
Electrolytes (Na, K, Cl-) Daily 1-2//wk
BUN 3/wk Weekly
Ca, P,mg 3/wk Weekly
Liver function Enzymes 3/wk Weekly
Serum triglycerides weekly weekly
CBC weekly weekly
27
Problems
  1. Catheter sepsis
  2. Placement problems
  3. Metabolic complications

28
Complications
  • Dehydration
  • Possible cause
  • Inadequate fluid support
  • Unaccounted fluid loss (e.g. diarrhea, fistulae,
    persistent high fever).
  • Management
  • Start second infusion of appropriate fluid, such
    as D5W, 1/2NS, NS.
  • Estimate fluid requirement and adjust PN
    accordingly.

29
Complications
  • Overhydration
  • Possible cause
  • Excess fluid administration
  • Compromised renal or cardiac function.
  • Management
  • Consider 20 lipid as calorie source
  • Initiate diuretics.
  • Limit volume.

30
Complications
  • Alkalosis
  • Possible cause
  • Inadequate K to compensate for cellular uptake
    during glucose transport
  • Excessive GI or renal K losses.
  • Inadequate Cl- in patients undergoing gastric
    decompression.
  • Management
  • KCl to PN.
  • Assure adequate hydration.
  • Discontinue acetate.

31
Complications
  • Acidosis
  • Possible cause
  • Excessive renal or GI losses of base
  • Excessive Cl- in PN.
  • Management
  • Rule out DKA and sepsis.
  • Add acetate to PN.

32
Complications
  • Hypercarbia
  • Possible cause
  • Excessive calorie or carbohydrate load.
  • Management
  • Decrease total calories or
  • CHO load.

33
Complications
  • Hypocalcemia
  • Possible cause
  • Excessive PO4 salts
  • Low serum albumin.
  • Inadequate Ca in PN.
  • Management
  • Slowly increase calcium in PN prescription.

34
Complications
  • Hypercalcemia
  • Possible cause
  • Excessive Ca in PN
  • Administration of vitamin A in patients with
    renal failure.
  • Can lead to pancreatitis.
  • Management
  • Decrease calcium in PN.
  • Ensure adequate hydration.
  • Limit vitamin supplements in patients with renal
    failure to vitamin C and B vitamins.

35
Complications
  • Hyperglycemia
  • Possible cause
  • Stress response. Occurs approximately 25 of
    cases.
  • Management
  • Rule out infection.
  • Decrease carbohydrate in PN.
  • Provide adequate insulin.

36
Complications
  • Hypoglycemia
  • Possible cause
  • Sudden withdrawal of concentrated glucose.
  • More common in children.
  • Management
  • Taper PN. Start D10.

37
Complications
  • Cholestasis
  • Possible cause
  • Lack of GI stimulation.
  • Sludge present in 50 of patients on PN for 4-6
    weeks
  • resolves with resumption of enteral feeding.
  • Management
  • Promote enteral feeding.

38
Complications
  • Hepatic tissue damage and fat infiltration
  • Possible cause
  • Unclear etiology.
  • May be related to excessive glucose or energy
    administration
  • L-carnitine deficiency.
  • Management
  • Rule out all other causes of liver failure.
  • Increase fat intake relative to CHO.
  • Enteral feeding.

39
Refeeding Syndrome
  • What is it?
  • Severe fluid and electrolyte shifts and
    related metabolic disturbances found in
    malnourished patients being re-fed.

40
Refeeding Syndrome
  • Who is at risk?
  • - Chronic alcoholics
  • - Chronic malnutrition
  • - Anorexia nervosa
  • - Patients unfed for 7-10 days with evidence of
    stress/depletion
  • - Oncology/haematology patients
  • - Morbid obesity (weight loss gt10 over the
    previous 3 months

41
Refeeding Syndrome
  • Consequences
  • - Hypophosphataemia
  • - Hypokalaemia
  • - Hypomagnesaemia
  • - Altered glucose metabolism
  • - Altered fluid status
  • - Vitamin deficiency

42
High risk of refeeding problems
  • Consider
  • Increasing levels slowly
  • Restoring circulatory volume and monitoring
    fluid balance and clinical status
  • Providing a multivitamin/trace element
    supplement
  • Providing extra potassium, phosphate and
    magnesium

43
Transition from PN to EN
Schedule PN ml/hr EN ml/hr
Day1 100
Day 2 Decrease by 10-20 20-30
Day3 Decrease by 10-20 30-40
Day 4 Decrease by 10-20 40-50
Day5 Stop PN Increase 10ml/hr every 24 hr
Increase 10ml/hr every 24 hr
Increase 10ml/hr every 24 hr
44
Thank you
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